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Social Work and Social Policy



Department of Medico-Social Sciences
Faculty of Public Health, Health Care and Sports
South-West University “Neofit Rilski”
Blagoevgrad, Bulgaria
Received: 28-June-2021
Revised: 03-August-2021
Accepted: 11-August-2021
Online first: 16-August-2021

1. Introduction

The way of supporting people with mental health issues has changed in the last decades. The use of a complex approach that includes medical observation of the symptoms and the psychosocial rehabilitation, directed towards recovery or improvement of the social functioning, has the goal to improve their quality of life and social inclusion (Matanova, 2018; Stancheva-Popkostadinova, 2004b).
Social work has an important place in the care for people with mental illness. It is a “humanly oriented activity” (Derizhan, 2010, p. 62), aimed at “optimising the mechanisms of social functioning” (Sotirova, 2011, p. 32) by cooperation with the client, directing the personality towards the use of its own resources, empowerment and self-actualization (Miteva, 2006, p. 11). Helping relationships through social work encourage and stimulate the potential of the individual to become “a subject of their own development and an active participant in the two-sided process” (Cholakova, 2016, p. 19).These characteristics of social work define it as an inseparable part of rehabilitation, with the aim of recovery from mental illness, which is described as “a process of transformation and empowerment of individuals with mental issues or behavioural dysfunctions, with which a wholesome life in society and realization of the full potential of an individual can be achieved” (Milusheva, 2018, p. 48). According to Deegan (2005, p. 6) the recovery is “hard work” that “requires personal agency, will, vision, hope, fortitude, courage, imagination, commitment, and resilience”.
Empowerment, which is the basis of social work and rehabilitation of mental illness, can be generalised as the presence of control, development of skills and proactive behaviour (Zimmerman, 2000), power, participation and control over one’s own life (Hansson & Bjorkman, 2005), power to make decisions and self-esteem (Rapp, Sheen, & Kristhardt, 1993), self-efficacy (Corrigan, Faber, Rashid, & Leary, 1999; Lord, &Hutchison, 1993). In the context of support for people with mental disabilities empowerment is closely connected with control over the services used and, in the wider sense, with control over all areas of their life (Corrigan, 2004). The mental illness determines the presence of disorders in the social functioning of the individual (Stancheva-Popkostadinova, 2004b) and the need for complex support, directed towards recovery. There is mutual connection and justification between social work and support, rehabilitation, social functioning, empowerment and quality of life.
The aim of the current article is to present a narrative review of literature related to empowerment theory, empowerment as an approach to the social support of people with mental disabilities, and the impact of such an approach on the domains of their social functioning. Literature sources were identified by searching the databases: EbscoHost Academic Search, Science Direct, Scopus, IST Web of Science by keywords: empowerment, social functioning, people with mental disability.

2. Empowerment as a concept

Empowerment cannot be subjected to a generally recognised definition and general concept (Bailey, 2010; Cholakova, 2018; Hansson & Björkman, 2005; Rogers et al., 2007; Sakellari, 2008). It has many fields of application and can be seen both as a process and a result (Cholakova, 2018; Maton, 2008; Zimmerman, 2000), as well as “intervention, all-encompassing frame of mind and action etc.” (Cholakova, 2018, p. 198). Empowerment is defined as “multi-level” (Rappaport, 1987) and “a multi-component construct that likely varies across populations and contexts” (Christens, 2012b, p. 115; Zimmerman, Israel, Schulz, & Checkoway, 1992).

The basic elements and characteristics of empowerment according to different authors can be presented as follows:

  • Empowerment is connected with understanding the forms of oppression and with the release of individuals, groups and communities to achieve their full potential (Perkins, 2010).
  • It requires a change of the paradigm: creating a closer relationship with the clients, focusing on development of their strong suits and moving from a dependence to self-help (Perkins, 2010).
  • Psychological empowerment includes intrapersonal (accepted control and self-effectiveness, motivation for control, accepted competence and mastery), interactive (understanding of community) and behavioural components (Zimmerman, Israel, Schulz, & Checkoway, 1992; Zimmerman, 1995).
  • Empowerment “embodies such concepts as confidence, control, decision authority, influence, autonomy, and self-trust” (Rapp et al., 1993, pp. 732-733).
  • It is separated on different levels: individual level, organisational level and society level that are not fixed in certain borders and are highly interactive (Christens, 2012a; Maton, 2008; Perkins & Zimmerman, 1995; Zimmerman, 1995; Lord & Hutchinson, 1993).
  • It is connected with the feeling of personal control (Maton, 2008; Riger, 1993; Lord & Hutchinson, 1993).
  • It is realised “in and through relationships, as well as emotional, cognitive and behavioural processes” (Christens, 2012b).
  • It can hardly be quantified because of its specific characteristics: it is shown in different values, skills and behaviour in people; change of the conditions requires different beliefs, competences and actions; also, personal empowerment can change with time (Zimmerman, 1990a, 1995).
  • Empowerment of individuals cannot be seen outside the context of participation in the community (Lord & Hutchison, 1993; Perkins, 2010; Rappaport, 1987; Speer, 2000; Zimmerman, 1990a, 1990b).
  • Empowerment promotes self-efficacy (Lord & Hutchison, 1993).

3. Support for people with disabilities, based on the empowerment approach

The approach of empowerment, as a basic element of effective social work (Beaulaurier & Taylor, 2001), used when providing services for people with disabilities is defining for the improvement of the functioning of the individual and his skills (Patchner, 2005). The support provided for people with disabilities has a direct connection with the perspective in which the disability is seen. “The focus of the problem, according to the rehabilitation paradigm, is in the individual; the solution rests with professionals” (Segal, Silverman, & Temkin, 1993, p. 706). The paradigm of independent living “locates the problem in the environment and the rehabilitation process”, the solution lies in “peer counseling, advocacy, self-help, consumer control, and removal of environmental barriers” (ibid). The approach of empowerment is applicable in health care as well as when we are discussing people with disabilities. Bravo, Edwards, Barr, Scholl, Elwyn, McAllister, & Cochrane Health Care Quality Research Group (2015) identify the role of medical interventions and define self-efficiency, the perceived personal control, the level of participation when making a choice and autonomy as indicators for empowerment of patients in health care. A direct connection between the level of empowerment and the medical condition of patients (Náfrádi, Nakamoto, Csabai, Papp-Zipernovszky, 2018), as well as with the quality of health care (Vainauskiene & Vaitkiene, 2021). It requires recognising the patient as an expert and participant in the treatment, not only as the receiver of such (Tveiten, Hauklond, & Onstad, 2001).
Keyes, Webber, & Beveridge (2015, p. 246), studying the connection between care in social services and empowerment, define the relationship of codependence, equality, partnership and dialogue with the users on all levels of the service and “through the recognition of the rational and actual autonomy” as basic requirements for the process of empowerment. Empowering care begins with understanding the person and his needs, by providing opportunities, effective use of resources, a flexible process of support and control of the service by the very users (ibid).
Linhorst, Hamilton, Young, & Eckert (2002) in a study of the barriers to empowerment of people with severe mental illness, identify all people to be empowered, which can be explained by the understanding of Prilleltensky (2008, p. 119) about power as “a combination of ability and opportunity to influence a course of events” encompassing the freedom of action and willful actions with outside determinants of the environment.
The studies show that in the context of social services the model of empowerment has to be in accordance with the cultural particularities of the specific communities and groups. (Cholakova, 2018).

4. Empowerment in the context of social support for people with mental disorders

In the current article, viewing empowerment in the context of social support for people with mental disorders, has two main goals. First: to define the connection between mental disorders, social support and social functioning – which are determining factors for the wellbeing and quality of life. Second: to identify the connection between empowerment and the functioning of persons with mental disorders. The results are presented in Figure 1.

Figure 1: Effect of mental disorder and empowerment on social functioning.

Good functioning is connected with mental wellbeing, and it includes several components: self-acceptance, positive relationships with others, autonomy, personal development, having a goal in life, possessing skills for choice and creating a proper environment for personal mental development (Ryff, 1989; Ryff & Keyes, 1995). The separate fields of social functioning are connected and supplementary, which defines the possibility for a disability in one area to lead to disabilities in another (Ryu, Lee, Lee, Nam, Chung, & Kim, 2020) or the other way around – affecting one area of social functioning will lead to improvements in another and in the whole. Infringement of the functioning is defined as an inability to fulfill certain social roles (ibid).
Social functioning is seen as a complex construct, defined by the interaction of different factors, including the symptoms of the mental disorder (Simons, Bartels-Velthuis, Pijnenborg, & Genetic Risk and Outcome of Psychosis (GROUP) Investigators, 2016). The mental illness is characterised with an infringement of the functioning (Miteva, 2010), which, in some of the patients, is restored after the first episode of the illness (Robinson, Woerner, Meniman, Mendelowitz, &Bilder, 2004; Ryu et al., 2020; Tohen et al., 2000). A study of Antonova, Mineva, & Dimitrov (2017, pp. 201-202) shows that the persons with mental disorders have high levels of loneliness and problems in the processes of separation-individualisation: “lack of personal borders, inability to stand loneliness and problems with trust and control when building and maintaining relationships with others”, as well as the presence of causality between the two. To this end, it is necessary to emphasise the effectiveness of the treatments used, in order to increase the level and period of recovery. This requires an analysis of the factors, which are determining the functioning of the specific individual case.
One if these factors is the diagnosis (Ryu et al., 2020). The results determine the area of “cognition” as central in the network of social functioning of people with schizophrenia and bipolar disorder. The possibilities and need for inclusion in cognitive therapy when treating severe mental illnesses is identified (Ryu et al., 2020; Tripathi, Kar, & Shukla, 2018). A correlation is found with the results of another study of people with mental illness that shows a higher level of empowerment in persons with bipolar disorder compared to those with schizophrenia (Lloyd, King, & Moore., 2010). It underlines the need for researching the history of the people when performing therapeutic work with them, implementing assertive and integrated treatment, duration, and continuation of the care (van Kranenburg et al., 2020).
Recent studies show a significant and negative connection between mental disorders and the perceived social support, which underlines the role of support, provided by family and friends (Vaingankar et al., 2020), as well as the one that is provided by social services (Bjørlykhaug, Karlsson, Hesook, & Kleppe, 2021). Another study also identifies the effect of social support and the participation in different activities on the process of recovery from mental illness. (Hendryx, Green & Perrin, 2009).
The second aim of this article is identifying the connection between empowerment and social functioning in people with mental disorders. To this end, empowerment is seen as a mandatory element and a basic principle of support of people with mental health issues (Segal et al., 1993; Stromwall & Hurdle, 2003; Ntshingila, Temane, Poggenpoel, & Myburgh, 2021), which is a result of its direct connection with improving the quality of life (Sakellari, 2008; Vauth, Kleim, Wirtz, & Corrigan 2007), and social inclusion and recovery (Berry, Allott, Emsley, Ennion, &Barrowclough, 2014; Lloyd et al., 2010; Sapundzhiev, 2017).
Empowerment affects the entire social functioning (Berry, Allott, Emsley, Ennion, & Barrowclough, 2014; Hansson & Björkman 2005) in different ways. It is necessary to underline the connection between empowerment and its result, connected with the adherence and results of treatment. One of the ways for empowerment of people with severe mental illness is their participation in the treatment planning process (Linhorst et al., 2002) and shared decision making (Mahone et al, 2011).
Another way is by applying a consumer-directed approach (Kosciulek & Merz, 2001) and the participation of the users in the entire process of care – from its planning to assessment of the end results (Salzer, 1997). It requires changing the focus from helping or work with people with mental disorders to cooperating with them (Kondrat & Teater, 2009) with an emphasis on the choice and control of the client (Linhorst et al., 2002).
Meta-analysis of the literature that discuses employment of persons with mental illness, determines cognitive functioning, social support, rehabilitation services for recovering functioning as important predictors of employment of people with mental illness (Tsang, Leung, Chung, Bell, & Cheung, 2010). The connection between empowerment and employment is two-sided. On one hand, the level of empowerment is determined as a factor for employment, while on the other, employment helps to improve the control over their life for people with mental illness. It is necessary to underline that when assessing the functioning, connected with employment, there are difficulties caused by the need to simultaneously assess both objective factors connected with employment, and subjective components determining the satisfaction of the relationships through employment (Hui et al., 2013). The assessment and analysis of the results of the program for educating young people with special needs with employment skills based on the empowerment approach, links its effectiveness to employment training and life skills (Krajewski et al., 2010). Empirical data exists, which demonstrates the influence of employment (in a competitive environment) on the level of empowerment in people with mental illness (Hansson & Björkman, 2005; Lloyd et al. 2010; Sá-Fernandes, Jorge-Monteiro, & Ornelas, 2018) and their recovery (Lloyd et al., 2010). Size of income (as part of the quality of life) has a role in interpersonal relationships, reduces worries about the future and ensures personal feelings of empowerment (Sá-Fernandes et al., 2018). The determined relationship is explained, because the participation in employment activities is linked to motivation, building competence and developing self-identity. (Mee, Sumsion, & Craik, 2004).
Empowerment of people with mental illness is connected with participation in activities in the community (Rogers, Chamberlin, Ellison, & Crean, 1997). A study, which assesses the results of participation of people with mental disorders in projects connected with art, shows that the use of these methods has positive results on empowerment, mental health and social inclusion (Hacking, Secker, Spandler, Kent, & Shenton, 2008).
In the context of providing support with means of social services, a study of Hultqvist, Eklund, & Leufstadius (2015) of people with mental disorders, who use social services (DayCentre) shows a correlational relationship between empowerment and employment, satisfaction of the service used and self-assessment of the health and psychological symptoms. It must be highlighted that the process of empowerment in the access of services for people with mental health problems, such as day centres, include complex interactions of individual, social and material factors (Sutton, Bejerholm, & Eklund, 2019). When performing the rehabilitation process, it is necessary to consider all the experiences and expectations of the individual (Hillborg, Svensson, & Danermark, 2010), as well as compliance with their needs, environment, cultural and socio-economic conditions (Stancheva-Popkostadinova, 2004a). A study of Rogers at al. (2007) on the effectiveness ofprograms encouraging the empowerment of users of programs in the mental health services, underlines the need for implementing individual approaches towards the implication of such programs, as well as when assessing their effectiveness. According to Deyanova (2014, p. 36) the whole functioning of persons with mental disorders is positively affected with the use of “a systematic and targeted work, compliant with the health, mental, social, economic, educational and emotional” status of the client. A study of the author determines the positive influence of working in groups on the emotional functioning of persons with mental disorders (ibid).
In the rehabilitation process and support of persons with mental illness, one of the main problems with which they faced is the stigma (Lloyd, Waghorn, & Williams, 2008; Yotsidi & Kounenou, 2018) and the self-stigmatisation (Girma et al., 2013), which can be a result of the strategies for managing people with mental illnesses, connected with self-isolation and maintaining a secret. (Vauth et al., 2007). Vauth et al. (2007) discover a connection between self-stigmatisation, self-effectiveness, empowerment, quality of life and depression. Higher levels of self-stigmatisation reduce self-effectiveness, which undermines empowerment (ibid.). On the other hand, empowerment is determined as a valuable tool to fight self-stigmatisation, by increasing the self-esteem, self-assurance, self-effectiveness and stigma in society with persons with severe mental disabilities (Girma et al., 2013; Kondrat & Teater, 2009; Sakellari, 2008).

5. Conclusion

The present study aimed to show the basic concepts of empowerment and their application when providing support for people with mental disorders, during their recovery process. Empowerment is defined as a multi-level and multi-component construct, which takes an important place in the conceptual frames of social work and rehabilitation support for people with mental disorders. The data of the current study identifies the connection between the theoretical understanding of empowerment and its practical application in the process of prevention and recovery of social functioning of people with mental disorders, which is directly connected with their quality of life. The main elements and mechanisms of empowerment were identified: participation in the community, employment, wholesome inclusion in the process of planning and providing support. The outlined connection can inform the service providers when planning and providing effective support of people with mental disabilities, with the aim to improve their social functioning and quality of life.

Conflict of interest

Author declares no conflict of interest.


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How to cite this article: Stoykova, M. Empowerment and Social Functioning of People with Mental Disabilities. Journal for ReAttach Therapy and Developmental Diversities. 2021 Oct 25; 4(1): 39-49.

Copyright ©2021 Stoykova, M. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0)

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